Healthcare Provider Details

I. General information

NPI: 1275002230
Provider Name (Legal Business Name): ALYSON VANYA CPNP-PC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2018
Last Update Date: 03/22/2021
Certification Date: 03/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1008 DICKERSON DR
JASPER TX
75951-5111
US

IV. Provider business mailing address

1008 DICKERSON DR
JASPER TX
75951-5111
US

V. Phone/Fax

Practice location:
  • Phone: 409-489-9322
  • Fax:
Mailing address:
  • Phone: 409-489-9322
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberAP139783
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: